Integrated Practices | Comprehensive Care

January 5, 2024   

In this issue we feature:  

LUGPA is Fighting Pending Cuts to Physician Pay

On January 1, the 2024 Medicare Physician Fee Schedule final rule implemented a 3.37 percent cut in the conversion factor effective January 1, impacting Medicare payments to physician practices.

While House and Senate committees advanced legislation in November to mitigate these cuts, a floor vote has not yet been scheduled.  CMS could ask providers to hold claims in anticipation that legislation to blunt the cuts will be enacted in mid-January, but that looks uncertain at this time.

The cut is compounded by a projected 4.6 percent increase in practice cost expenses, potentially resulting in a real 8 percent reduction for physicians. This trend follows a 26 percent decline in Medicare physician payments when adjusted for inflation from 2001 to 2023, as reported by the American Medical Association. Continuous reimbursement cuts may have far-reaching implications, especially in rural and underserved communities, jeopardizing the ability to serve new Medicare patients.

LUGPA launched a grassroots effort with Congress to bring attention to this issue, where many of our doctors contacted members of Congress to support the letter to bipartisan leadership asking that cuts be replaced with a stable payment system that ties reimbursement to the Medicare economic index, i.e., practice costs.

One bill that achieves this goal, which LUGPA has supported, is the "Strengthening Medicare for Patients and Providers Act" (HR 2474), which links payments to the Medicare Economic Index. Furthermore, LUGPA has called for the creation of a new reimbursement determination method, highlighting a positive development in the form of the Medicare Payment Advisory Commission's (MedPAC) recent recommendation to tie physician payment updates to the Medicare Economic Index for the first time.

LUGPA's Health Policy and Advocacy committees wanted to express our gratitude for the grassroots efforts and support to the LUGPA members who encouraged their local elected officials to sign an important Dear Colleague letter that has been sent around Congress.

The letter urges Congressional leadership to prevent the 3.37 percent cut to Medicare reimbursement payments on January 1, 2024 and has garnered an impressive 194 Members' signatures. Despite Congress's expectation to recess before finalizing, there is optimism that a healthcare package addressing these cuts will be considered upon their return in early January.

For additional information on the Medicare Physician Fee Schedule Payment Cuts, LUGPA has provided a resource page.


House Passes the Lower Costs, More Transparency Act

The Lower Costs, More Transparency Act (LCMTA) (H.R.5378) is a comprehensive legislative initiative designed to bolster price transparency in healthcare, address prescription drug costs, and support various stakeholders in the healthcare system. The bill, incorporating elements from multiple proposed bills in 2023, mandates healthcare providers and insurers to disclose specific information about healthcare costs. It also establishes requirements for payment methodologies under Medicare and Medicaid, extending various public health programs. Notably, the legislation requires disclosure of prices by hospitals and ambulatory surgical centers participating in Medicare, including discounted cash prices and negotiated charges.

A significant focus of the LCMTA is on pharmacy benefit managers (PBMs). The bill obliges PBMs to report claims for covered drugs to health plan sponsors semiannually and enforces pass-through pricing models while prohibiting spread pricing for PBMs under Medicaid. Section 203 of the bill implements site-neutral payments for drug administration in off-campus hospital outpatient departments to the physician office level over five years, which LUGPA strongly supports. That provision saves Medicare $3.8 billion over ten years and an additional $760 million in out-of-pocket costs for patients.

During our annual fly-ins, LUGPA has been actively advocating in Congress on the positive impact of site-neutral payment reforms on lowering patient costs, stabilizing Medicare, and fostering transparency in the healthcare marketplace. The bill has passed the House with bipartisan support.

   Detailed CBO Score: A net reduction of $290 million over a 10-year period (2024-2033).
   For an in-depth analysis of the legislation, please refer to the attached document.

For further details, the updated proposed bill can be accessed here. A LUGPA Policy Update on the bill is available here.


Better Mental Health Care, Lower-Cost Drugs, and Extenders Act 

In December, Senate Finance Committee Chair Ron Wyden and Ranking Member Mike Crapo reported legislative text from the committee's November markup titled the "Better Mental Health Care, Lower-Cost Drugs, and Extenders Act." This bipartisan legislation addresses key healthcare priorities within the committee's jurisdiction.

The proposed act focuses on improving mental health care, addressing drug price middlemen, and preventing unnecessary cuts to essential health services. The legislation expands mental health care and substance use disorder services under Medicaid and Medicare, reduces prescription drug costs for seniors, extends expiring Medicaid and Medicare provisions, and mitigates pending cuts to physicians and other providers by reducing 3.4% cut to 2.15%. The bipartisan approach aims to cut patient costs at the pharmacy counter, enhance provider choice for seniors, and reverse incentives favoring higher-priced medications without increasing the federal deficit.

The legislation received unanimous support from the Finance Committee. The final reported legislative text can be found here. A section-by-section summary can be found here.


CMS Finalizes Rule on Federal Medicaid Renewals Enforcement

On December 6, The Centers for Medicare & Medicaid Services (CMS) issued a final rule with a request for comments (IFC) to enforce state compliance with reporting and federal Medicaid renewal requirements under Section 1902(tt) of the Social Security Act. This rule, in accordance with the Consolidated Appropriations Act, 2023 (CAA, 2023), aims to ensure that states adhere to federal requirements related to Medicaid coverage renewals after the Families First Coronavirus Response Act (FFCRA) section 6008(b)(3) continuous enrollment condition.

The rule grants CMS the authority to require states to submit a corrective action plan (CAP) if they are non-compliant with data reporting or eligibility renewal requirements. If states fail to submit or implement a CAP when required, procedural disenrollments may be suspended, civil money penalties may be imposed, and a reduction in a state's Federal Medical Assistance Percentage (FMAP) may occur.

The full IFC document, CMS-2447-IFC, can be accessed on the Federal Register website at


CMS Releases Medicare Prescription Drug Inflation Rebate Program Revised Guidance  

On December 14, The Centers for Medicare & Medicaid Services (CMS) released revised guidance for the Medicare Prescription Drug Inflation Rebate Program, a component of President Biden's Inflation Reduction Act. The law requires drug companies to pay rebates to Medicare if the prices of certain prescription drugs administered or dispensed to Medicare beneficiaries increase faster than the rate of inflation.

The guidance outlines key requirements and procedures for calculating and invoicing rebates for certain drugs covered under Medicare Part B, and Part D. CMS has also released a list of 48 prescription drugs for which Part B beneficiary coinsurances may be lower between January 1, 2024, and March 31, 2024, potentially saving individuals with Medicare between $1 and $2,786 per average dose. The guidance aims to discourage excessive price increases, protect Medicare beneficiaries, and make healthcare and prescription drugs more affordable. The Medicare Prescription Drug Inflation Rebate Program is set to issue invoices to drug companies for rebates starting in 2025, covering years 2022, 2023, and 2024.

The revised guidance addresses challenges related to drug shortages and severe supply chain disruptions, seeking to strike a balance between discouraging price increases and providing relief to companies facing disruptions. The program aligns with CMS's goal of making drugs more affordable and accessible while safeguarding the pharmaceutical supply chain.

A fact sheet on the Medicare Prescription Drug Inflation Rebate Program revised guidance is available here

divider Federal Independent Dispute Resolution (IDR) Process Administrative Fee and Certified IDR Entity Fee Ranges Final Rule   

On December 18, the Departments of Health and Human Services, Labor, and the Treasury released the final rule governing fees associated with the Federal Independent Dispute Resolution (IDR) Process under the No Surprises Act (NSA). A critical component of the Consolidated Appropriations Act of 2021, the NSA addresses payment disputes between plans, issuers, healthcare providers, facilities, and air ambulance services. The rule establishes administrative and certified IDR entity fee ranges, providing clarity and parameters for dispute resolution in the Federal IDR process, which is crucial for determining appropriate payment amounts for out-of-network items and services during disagreements.

To enhance transparency, the rule outlines a methodology for determining the administrative fee, aligning with statutory requirements. The administrative fee, applicable to both disputing parties, is set at $115 per party for disputes initiated on or after the rule's effective date. The rule also introduces fee ranges for certified IDR entities, addressing concerns raised in recent legal cases. For single determinations, the fee range is $200-$840, and for batched determinations, it is $268-$1,173.

While LUGPA supports Congress's efforts to improve insurer obligations under the NSA and acknowledges the positive aspects of the final rule, it emphasizes the need for further enhancements. The rule fails to address the fundamental issue of insurers compelling providers into the IDR process with inadequate payment rates for essential emergency services. Additionally, the absence of rules establishing oversight and enforcement mechanisms for inappropriate practices within the IDR process is a notable gap. LUGPA advocates for a more comprehensive effort to transform the IDR process into the impartial system envisioned by Congress.

For comprehensive details on the final rule, please refer to the fact sheet here

divider LUGPA Policy Brief: The Importance of Germline and Somatic Genetic Tests in Urological Practice

This policy brief emphasizes the crucial role of genetic testing in urological practice, particularly for conditions like prostate, kidney, and bladder cancers. Germline and somatic genetic tests are instrumental in identifying genetic alterations that influence disease susceptibility, progression, and treatment response. Early detection and risk assessment are highlighted as key benefits, enabling the creation of personalized screening plans and guiding treatment selection through precision medicine.

The brief emphasizes the need for congressional action to protect and enhance access to genetic testing, including coverage considerations, awareness promotion, and research support. The Reducing Hereditary Cancer Act (H.R. 1526) is highlighted as a bipartisan effort addressing limitations in Medicare coverage for genetic testing, aiming for comprehensive coverage and aligning with NCCN guidelines.  

The full Policy Brief is available here.


Medicare Local Coverage Determination Updates  

A58371: Billing and Coding: MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease 

L38303: MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease   

L38707 (Future): Transurethral Waterjet Ablation of the Prostate   

A58229 (Future): Billing and Coding: Transurethral Waterjet Ablation of the Prostate         

A59597 (Future): Response to Comments: Transurethral Waterjet Ablation of the Prostate         

L38705 (Future): Transurethral Waterjet Ablation of the Prostate   

A58227 (Future): Billing and Coding: Transurethral Waterjet Ablation of the Prostate         

A59596 (Future): Response to Comments: Transurethral Waterjet Ablation of the Prostate          

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